Casey A. Grover, MD

Drug-seeking behavior is a common and growing problem in emergency departments nationwide. New research on drug-seeking patients in the ED has worked to quantify how frequently several strategies are used by drug-seeking patients to obtain medications.

Pain is one of the most common reasons for patients seeking care in EDs, accounting for up to 42% of all emergency room visits. Emergency physicians vary widely in prescribing patterns and often have difficulty assessing patients’ level of pain. There may also be reluctance to provide pain medications due to concerns that patients are trying to obtain prescription drugs for non-therapeutic purposes. “These individuals— who are often labeled as drug-seeking—are a difficult group of patients to manage in the ED,” says Casey A. Grover, MD. “They often present to the ED with conditions that are difficult to evaluate, and may also engage in deceptive behaviors in an effort to fool clinicians into giving them additional medications.”

It is estimated that up to 20% of all ED visits may be due to drug-seeking behavior. “Drug-seeking patients have been known to use large amounts of medical resources,” says Dr. Grover. “They may occupy beds in EDs that would be more appropriately used for people truly in need of emergency care.”

Prescription drug abuse and misuse is a growing epidemic throughout the United States, and more and more emergency physicians are encountering drug-seeking patients in daily practice. “Despite the magnitude of the problem,” Dr. Grover says, “there is still much to learn about these patients, their patterns, and how best to manage them.”

Intriguing New Data on Drug-Seeking Behavior

Studies have been conducted on screening tools to identify drug-seeking behaviors in chronic pain patients, but few have provided quantitative data on such behaviors in the ED. With this in mind, Dr. Grover and colleagues performed a case-control study examining the relative frequency of various drug-seeking behaviors in drug-seeking patients as compared with all ED patients. The study was published in the January 2012 Journal of Emergency Medicine. “Our goal was to provide emergency physicians with information as to which drug-seeking behaviors are most commonly used by drug-seeking patients,” says Dr. Grover. “Identifying behaviors that are most commonly used by drug-seeking patients may help evaluations of patients suspected of drug-seeking behavior.”

A retrospective chart review of 152 drug-seeking patients and of age- and gender-matched controls was conducted, with the authors noting several drug-seeking behaviors that were exhibited over 1 year. Drug-seeking patients accounted for 2,203 visits to the ED, averaging about 14.5 visits per patient per year. For the control group, patients accounted for 315 visits to the ED, which is an average of 2.1 visits per patient per year. Patients in the drug-seeking arm reported their pain level as 10 out of 10 more often than control group patients (Table 1). Additionally, drug-seeking patients occasionally complained of pain levels greater than 10 out of 10, while the control group had no instances of these events. Drug-seeking patients were also significantly more likely to request medications parenterally.

The odds ratios for both requesting parenteral medication and reporting pain levels greater than 10 out of 10 were significantly higher than all others observed in the study (Table 2). These were the most predictive of drug-seeking behavior, while a non-narcotic allergy was less predictive. However, the odds ratio for a non-narcotic allergy was greater than 1, and was still a behavior that was more commonly used by drug-seeking patients than the control group. For other studied behaviors, the confidence intervals were too wide to allow the authors of the study to meaningfully interpret the data.

Challenges Remain in Deciphering Pain

According to Dr. Grover, chronic narcotic use can make patients more sensitive to pain. “These individuals may truly be suffering from the most severe pain possible. On the other hand, patients with narcotic abuse and dependency often exaggerate pain complaints in order to get their desired medication. Chemical dependency can become a major motivating factor for patients to seek emergency care. Unfortunately, it’s nearly impossible to definitively determine if they’re seeking care in an attempt to get medications for non-therapeutic reasons.” The current literature on drug-seeking patients consists largely of small studies, according to Dr. Grover, and larger-scale studies are needed. “These efforts will hopefully help us gain a better overall picture of the frequency of these behaviors and eventually help us establish strategies to optimize how we manage drug-seeking patients.”

23 Comments

Misses Boo
on December 2, 2016 at 12:48 pm

Hello my name is Boo and I am a drug addict and an Er drug seeker. I am in recovery now and have been for 21 months. It may not sound like much but, it is, seeing I have been an addict for 18 years. I used every trick including injuring myself to get narcotics. Every single time I walked into that Er I felt guilty. I made sure my symptoms would secure me a spot in fast track so I wouldn’t take up a bed that a truly sick person or someone in real pain needed. I never rated my pain a 10. I have 2 kids and a kidney stone in my past so…. I said usually said an 8. I read that ER physician to the drug seeker letter on Craig’s list and followed those instructions. I never used chest pain or the worst migraine ever as my excuse. I have resting tachycardia and high bp so I had symptoms of pain.

I have only been to the Er twice in the last 21 months and I was fully open about my addiction and my drug seeking and how guilty I felt about seeking. The doc said the following “you have to do what you have to do to get by. The main thing is that your clean and you have admitted what you have done. I am proud of you Boo”

The years of narc use masked 2 conditions, one of which is painful. I won’t touch narcotics.

I know a lot of drug addicts who sought drugs from the Er. They are red flagged and a few of them have been told to not go back to that hospital. They can’t do that. They have to provide services in an emergent situation. I have learned that I need to forgive myself and move on. We do need to make or try to make amends, which I did.

I want to take just a moment to tell you about the withdrawal so you can understand why addicts are so desperate that they will seek in the ers.

My own drugs of choice is 2 drugs. Tramadol, and OxyCodone 30s. The withdrawal is ridiculously torturous and can be quite painful. I began the tram because of endometriosis and that’s when it first came out under its brand name Ultram. I was told its a man made opiate and was NONADDICTIVE!! Ha! I got very addicted. Post surgery I was on Vicodin ES. I found Vicodin and Ultram gave me a great buzz. Little did I know I became addicted. I was taking about 900mgs a day. Had a grandmal seizure and brain damage.

ass cramps,
dizziness,
lethargy,
decreased appetite ,
shaking,
headaches,
eye aches (pain right over eyes looking up hurts bad),
panic attacks,
crankiness,
and stomach cramps from drinking water.
There are more and they vary from person to person. I hope this and especially the withdrawal list will help docs understand what drives an addict to go to the Er to seek.

What made you decide to get clean? How did you get through the withdrawal process? Congrats on getting/being clean and helping others to understand some of the inner workings and thoughts of ER drug seekers. Here’s to 21 more months of sobriety and beyond!

Can someone please explain something to me? OK I lived in Delaware and suffer from ulcerative colitis I was prescribed opiates from the gate at a very young age. At 15 I was put on tylenol3 by 23 I was on oxycontin 40s. Now after I me a seeker, the ERs never turned me away…they even went as far to tell me we aren’t giving you any narcotics but we will check you out to make sure your not seriously injured or whatever. So how do your ERs turn you away? I always thought this was illegal? Also why aren’t Doctors allowed to come out and say I think your a drug addict? I had a Dr tell me-after I finally went to my fave ER for help that they had been waiting for this day…why not just say it? I mean I understand they can get in trouble for accusing someone of something and its false but if its not the addict isn’t going g to complain?

I want to take a moment to point out how political and media-fueled fear of all opiates is affecting people with chronic pain. I am an RN. I am 32 years old. About 16 months ago, I started having terrible mid/upper back pain. I took tylenol and ibuprofen with no help. I tried physical therapy and a chiropractor – still no luck. My primary doctor reluctantly prescribes tramadol – this gets the pain down to a 5 or 6 only – which is not tolerable. They’ve started nortryptiline a few days ago. It is not helping. By MRI and x-ray, I have “mild disc degeneration and scoliosis to the right.” I should not be in this pain — but I am. I am suffering. I’m terrified of this pain with “no cause” and no hope – and doctors who are afraid/reluctant to relieve pain because of drug seekers. I don’t know what to do. I can’t go to the ER even when I’m 7-8/10 because I know I’ll be labelled as a drug seeker. This isn’t fair to millions of people like me who just want their suffering reduced to a tolerable level.

Your a nurse? There should be automatic trust in my opinion. As a nurse you probably have access to all the pain meds you could ever want. Even tho I dont know you I would assume you dont touch those pain meds . There is no reason why you shouldnt be allowed to get a narcotic medication that works, and I am sorry your so under medicated. The DEA needs to get off the docs backs so the docs can appropriately treat peoples pain!!!

I am a chronic pain patient started w a slipped disk too much hydrocodoen then a fractured cervical vertbrae too much oxy then the worstI got a lumbar spine Iinfection so painful I was kickd out of er 3 times crying bc security was gonna be called bc I was a seeker. Finally on my 3 visit over 6 months the infection had gotten so big I lost two vertebrae and a disk and spent 2 weeks in hosp- I was released w morphine to taper off the dilaudid hi dosed pump in hosp I didnt have insurance no primary I went to er on week 3 of iv antibiotics and was kicked out AGAIN as a seeker even tho ky mris zhow no bone diak and spinL compression- last time I had a seizure on tramadol tbey toook me to er handcuffed me to bed told me id tried to commit suicide by narcotic overdose and could not leave. They accused me of heroin abuse! I smoke pot yes to SLLEP bc lying down in unbearable… but now? I have no pcp she dropped me the er wont trear me and im considered a heroin user even tho I never tested positive for it orhad track marks…. sentara virginia beach will see me Iin their er AGAIN only next time w my lawyer so I get fair TREATMENT

I do not know how many times I have been to an ER because of pain. I get the same questions all the time, are seeing your specialist, when is your appointment, is this chronic. I get varied answers such as we do not treat chronic pain, this is not an emergency, I do not believe in giving pain medications. When I go it is because the pain is unbearable. I cannot take any NSAID’s like aspirin, tylenol, etc due to bleeding ulcers that are grade B because my stomach ends up bleeding and then I get admitted to the ER and scoped again. But they always think I am there seeking the drugs so they may give me some pain medication but they will give me low dosages and tell me to follow up with my doctor or pain management. Pain management only wants to do injections but I cannot have them due to my platelet levels being so low I could bleed to death. My GP does not want to prescribe pain medications so I am in a catch 22. It took me almost 4 years to find someone who would treat my condition and them I had to move because my health got worse. Oh yeah, if you go on pain meds you are expected to take them and maintain levels in your blood stream to ensure you are not selling them or giving them away or you get discharged from the practice. My chronic pain is not so unbearable I need them all the time but the way they have to protect their license is to make sure I am doped up appropriately. You cannot be honest because there is no winning. I decided when I get certain types of behaviors from staff I start filing medical board complaints on the state and federal levels. Because if I have to be in pain, they can take the hours of answering for their conduct and lack of treatment. I also advise the doctor now I would be doing so and its their choice. Treat me as a reasonable mature adult who makes health decisions with me not for me or spend the time writing more paperwork. I also let them know I realize it may not go anywhere but if they are going to waste my time I will take the time to make sure I waste theirs as well since in the long run time is equal to money in their field. I hate to have to use the system in this manner however my complaint of pain is legitimate and if you are going to treat me as a “seeker” I am going to take offense and I am going to report you. After a while when they get so many complaints, then the board will start taking them seriously due to the pattern of abuse or indifference on behalf of the provider you have seen

I too have chronic pain due to many different causes from musculoskeletal pain to Crohn’s disease so I feel your pain with this stuff. (No pun intended) A couple things I wanted to point out. First, Tylenol(acetaminophen) is a pain reliever/fever reducer and does not fall into the NSAID category. It is very well documented that over use of Tylenol can cause liver problems but since it is not an NSAID it shouldn’t cause stomach ulcer or stomach bleeding problems like ibuprofen or aspirin. Also, the most prescribed narcotic in the world is hydrocodone. Hydrocodone is almost always combined with acetaminophen. 500 mg acetaminophen = Vicodin while 325mg of acetaminophen= norco and 300 mg of acetiminophen= xodol. All of which are combined with either 5,7.5 or 10 mg of hydrocodone. So the notion of not being able to take Tylenol for the reasons stated are not as valid and if you tell the dr that and then are ok with taking Vicodin or norco or lortab or even Percocet (oxycodone/acetaminophen) then the dr might think you are just lying then to get narcotics. I’m not saying you are not in the pain you are in but being as consistent and accurate with the info you give plays a big role in how they view you from the start. Next, I will say that I like the approach of reporting them as a means to waste their time. They certainly have no problems playing games and wasting ours and we are still forced to pay in the end for a service that wasn’t acceptable for us and we all know how precious their time is to them just by how much of a hurry they seem to be in and interrupting patients and having a rushing type of attitude constantly so I do like that method of retaliation. For the record, I was not trying to attack you in the first half of my response, just trying to inform you and maybe help find a reason why they may be so hard pressed to give you something stronger. I’ve ran into problems also and even with them telling me I have a bowel obstruction, admitting me into the hospital then as soon as I’m up in the room, nurses and Drs start playing games with the pain meds only coincidentally. It infuriates me cuz I came for pain relief and I could sit at home in pain for free without dealing with childish games that I have to combat and fight about which makes my pain and blood pressure skyrocket! So hopefully this helps you in the future

You are the reason people don’t prescribe
You don’t bully people. By law they d not have to prescribe anything for pain. It won’t kill you. If they don’t treat diabetes htn…sure….fine….but pain….every complaint you make.will be “looked into”to make you feel better but even the medical.board can’t make anyone prescribe narcotics. If anyone hears that bs from you I hope they flag you and DC you immediately until no one sees you. You are digging your own hole.

I have been a chronic pain patient since 97.. I have been on and off of opioids . I had had multiple surgeries for my knees due to a auto accident.
My ED is great . I have gone in at the advice of a couple of my pain management Dr’s . I have 2 herniated disks and there have been times that the pain gets so horrible that I just couldn’t take it anymore. I called my pain dr and they advised me to go in. So I did. I am always up front with the ED. I tell the dr that what my condition is and that even though yes I am being treated for pain at that moment the pain is just too much for me to handle and that my medication isn’t helping as much as it should. They’ve always been great well with exception of one dr but everyone else has been great. They always give me pain treatment and usually do an x- ray to make sure I didn’t hurt myself in some way and may not know it. I find if I am just straight up and honest they are much more willing to help me. Also though I have had awful experience ‘ s at other ER’S . I had an ovarian cyst and I was driving while I was driving I had such sharp pains that I had to pull over so I was close to the ED and I went in and told them what was up . They acted like I had purposely made it up just to try for opioids. I told them they were hideous and I would not even send my dog to them. So I came to my hometown ED and they were awesome, I had been awaiting surgery for this issue however they got me on IV pain meds . They did a ultrasound and what the other ER failed to treat and could have been dangerous was that my ovary had been tortioned and it was in a dangerous position. So they got me admitted and I had surgery on a Saturday. My point is I get that the ED has to be careful however I don’t think there should be a set guide line for determining pain especially for chronic pain patient’s. We have chronic pain yes. However we get other injuries as well and if we are on something well if we came to you our medication is not doing its job as effectively as it should and we need just a tad more help. When this happens we are upset and scared and did not want to leave to come sit in a waiting room with “people with MORE emergent issues”. As the woman whose a nurse wrote… I was kind of offended by that statement because who are you to say that pain isn’t emergent? Unless you suffer from it then I’d wisely refrain from comments as such. We aren’t addicts .

Pain patients never rest; if we are not fighting pain that overwhelms our senses, we are fighting a nasty minded system that judges pain when they have none themselves!

Dad took 1 pain pill in college, felt heavenly & decided never to do it again; it could take him over if he did! And he didn’t because once upon a time, citizens felt responsible for their ethics & now, they want a big bad problem to be at fault; but the pill didn’t jump into anyone’s mouth; they had to take it off protocol which is illegal! How is that our fault who suffer such pain? That’s our crutches we depend on them we treat them as a valuable aid and are grateful for such relief so we can be more productive! I have never been without pain; never in my life!

Hi,
I have been doing some reading on this subject, as I had a recent applicable experience.
Please bear with me.

I arrived at a local, affluent neighborhood, ER, and was dropped off at the door by a friend I had asked to take me to the hospital.
I knew that he had other commitments, so I assured him that I could grad a cab home, once I’d been seen. It was only a few miles… I should note that most would consider the van I arrived in to be somewhat “beat up”.

I had been working in my garage all day, making room for new equipment. After unloading the last piece, I managed to hurt myself badly. I was sure I had broken my arm or wrist.

I entered the ER on my own, quite dirty, unshaven, and advised them right away that I was currently un-insured, un-employed, had no PCP, and was effectively broke.

They put me on an IV, which did little or nothing to relieve my pain. I was very self-conscious because I was moaning/wailing out loud. I was truly in an enormous amount of pain.

X-rays were taken, and I was moved back to the ER. Eventually, the Dr. returned and assured me that I would live, and nothing was broken. I had simply hyper-extended my wrist (sprained it).

I repeatedly expressed my concern regarding the level of pain I was in; expressing that I was worried that I had hurt myself badly, and did not know how I was going to pay for it. The Dr., as well as some other ER staff, assured me that severe sprains are very often much more painful than breaks, and can sometimes take months to heal.

I related to the Dr. that my back was itching terribly, and basically begged him, and anyone else nearby, for some implement I could use in my good hand, to scratch my back.
No one ever gave me anything. The Dr. said that he had added Benadryl, I believe, to my IV, to combat the itching. He asked if I had any allergies to drugs, and I told him that I did not, as far as I know. I mentioned that, many years prior, after having 4 impacted wisdom teeth removed, and dry-sockets developed, I was given demerol, which had no impact. I was given dilaudid, still no impact, I was then given, percodan, which seemed to help some. He wrote me a prescription for some pain-killer, splinted my wrist, and advised me that if I wasn’t comfortable with his diagnosis, I should follow up with a local specialist, or my PCP, A.S.A.P. I asked again if he was sure about my injury, and he walked me over to a PC where he showed me an x-ray. He basically said “See?… Nothing broken…”, then he walked me to the exit door. After waiting for some 30 minutes for a promised cab, I asked a patient in the parking lot if I could pay them for a ride home.

I spent the next couple of weeks in a fog of pain and sleep. I’d wake up in agony, take the meds, and fall asleep again.

To shorten the story a bit, I’ll skip some detail…

After almost a full year of thinking I was slowly recovering, I managed to secure insurance via a new employer. I immediately went in search of a second opinion. It was quickly discovered that I had a volarly dislocated distal radio-ulnar joint.

After hearing the same diagnosis from three different sources, I decided that I would have to let the specialist perform surgery. An open reduction, hopefully saving the distal radio-ulnar head.

I obtained the x-rays from my ER visit a year earlier, and asked the Dr. if the injury was visible in them. He documented that he could, indeed, see the injury in the original x-rays.

When picking up the x-rays from the ER, I also asked for the doctor’s notes.

Within the Dr’s notes, I find that he documented my extreme distress, wailing, and my concern over the injury, and how I was going to pay. I also find that he included the following…
“The patient seemed to have a very high tolerance for narcotic pain medication”
His notes relating to the x-rays stated “…no bone or joint abnormalities present”

Almost two years have elapsed now, since that night in the ER, and I know that the malpractice statute of limitations is approaching within weeks. I have had the surgery, ironically at the same hospital, where the distal end of my left ulna had to be cut off, and replaced with a $13,000.00 metal replacement. I am receiving bills in excess of $30,000.00, still suffering with a great deal of pain, and enduring permanent limited use of my left hand/wrist. The Dr. who performed the surgery stated that as a result of the injury/surgery, I now have osteo-arthritis in that wrist.

I questioned the Dr. regarding what should have been done immediately after the injury, and he stated that, if it had been diagnosed initially, a “closed reduction” could very likely have been performed within 6-8 hours of the injury. … It could/should have been “popped back in place”…

It is enormously clear to me, after doing some research, what happened that night.

The Dr. and ER staff had identified me as an ER drug seeker, and clearly treated me accordingly.
I fit the “profile”, if you will, like a glove.

I was dropped off alone by a beat-up van, at the most affluent ER in town…
I was dirty, disheveled, and unshaven…
I was un-employed, un-insured, broke, and had no primary care physician…
I was moaning/wailing out loud, with no regard for who might hear me…
I repeatedly related my pain level as 10/10, and may have even stated higher than 10.
I was able to articulate to the Dr. specific pain meds that had been ineffective in my past…

Clearly, as evidenced by his comment regarding my very high tolerance, the Dr. was sure of his diagnosis, and had decided that my extreme distress was un-warranted, or ignorable.
I recall that when the Dr. tried to check my supination/pronation by manually rotating my wrist, I screamed in pain, and he stopped. There is no mention in his notes regarding supination/pronation tests/results. In fact, my wrist was trapped in full pronation by the dislocation. The Dr. had a splint applied, locking my wrist in the least painful orientation, and checked it. He approved.
In my layman’s mind, I’m confident that a thorough test for supination/pronation would be a standard part of any examination relating to wrist pain/injury. This did not happen in my case, or the Dr. would have seen clearly that I was completely locked in full pronation.
I’m sure that closer examination would have quiclky revealed my serious injury.

If the injury had been discovered, I would not have been allowed to leave the ER.
I was in need of emergency surgery, closed reduction of the DRUJ in this case.

A DRUJ (Dislocated Radio-Ulnar Joint) is an incredibly painful injury. My wailing was justified.
When I continued to report enormous pain, the Dr. had to decide if I was really hurt, or dramatizing. Obviously, he concluded that additional diagnosis wasn’t warranted at that time. I should “… see this specialist, or your PCP… A.S.A.P…”
A DRUJ is not hard to identify… If you are looking for something…

I could really use some professional insight.

Have my Patient Rights been violated?
Have my Civil Rights been violated?

I have spoken with several malpractice attorneys, who have all declined the case, as “I didn’t die…” and “He instructed you to follow up…”

A.S.A.P.

Who gets to define that?
In MY mind, I DID follow up “A.S.A.P”. I went as soon as I could pay…
The Dr. knew that I was broke and un-insured.
He knew that I had no PCP, and that the specialist he noted does not see indigent cases.
I did actually call them at one point, and was advised that they would bill me, but that I would have to pay $100.00 before even being seen. I did not have $100.00 at that time.
Additionally, a medical professional, an actual Doctor, had assured me that I had simply sprained my wrist. From my perspective, he might as well have said “You’re fine…”.
What sort of “follow up” is normally required for a sprained wrist?
I recall having sprained my ankle once, but can’t recall any follow-up being required.

I am clearly a victim of ER profiling, for lack of a more descriptive term.

Please, if anyone can offer me any advice, I’d be very grateful.
I have approached the hospital’s patient relations staff, who promptly advised me that I am mistaken, and turned my complaint over to their Risk Management department, who has stated that their specialists do not see the injury in the original x-rays, so they will not accept my claim.

In other words… Sue us…

Help? Anybody? Am I simply out of luck?
I’ll watch my e-mail for any responses.

TO PETER M. BROWN:
Chronic pain is awful. Suffering is bad. No one is denying this. But opiates are dangerous and tolerance builds over time; that is why chronic pain that requires opiate treatment should ONLY be handled by a pain management specialist or at the very least by ONE physician. This is chronic pain only relieved by opiates; failing to MANAGE the opiate treatment is a diservice to the patient. Without management the tolerance for the opiates increases too rapidly and a person has to escalaute their dosages so rapidly that they reach and then exceed the safe dosage within months or years when they have a condition that last a life time. Pain management is not just about avoiding abuse; It’s primary goal is to treat a chronic condition as safely, effectively, and FOR AS LONG AS CAN BE DONE. I’m not saying chronic pain patients can’t come to the ER; only that they can not be treated with opiates.
Now if you have chronic pain not being managed by a specialist then you should. As an ER nurse, I can promise you that your 2-3 hour wait in triage is more likely because all of our beds are filled people whose pain, whether legitimate or not, can only be treated with an opiate. And if you have ever been in an ER then I can promise you that if you had any delay in your care it is because the ER is being drowned in overly demanding, rude, and most often threatening patients, again only treated by opiates.
TO CAROL:
If you have cancer, you would be better of treating it with medical marijuana along with your paych. I’m not just saying this, I’m not some up tight self rightious idiot that thinks drugs are just wrong. I just think they should be used in the best interest of the user.

I see both sides. I feel for people who suffer from Chronic Pain. I had cancer and took over 40 plus doses of radiation tonmy pelvis
Then came surgeries I lost count of those ! I am on a Pain Patch now and fear for the day I must go to ED
All I ask is give me a chance
My Pain is REAL
Put yourself inmy shoes

I think that Dr. Grover’s comment about the need of further research in the field of pain is very germane. This seems to be an aspect of the solipsistic nature of human beings. I would say that if you have not felt the pain of another person, you have absolutely no right to make judgements about that person’s physical or mental state. That includes everyone, including doctors and nurses. I know that Peter is serious about his condition and am appalled at his doctor’s lack of understanding and compassion

I would like to add an additional comment to the ones I’ve posted above. My major concern is that ED doctors might be operating under the delusion that it’s somehow possible to determine whether a patient is truly in severe pain or whether they are faking it in order to get high. ED doctors must come to the realization that a considerable amount of harm can come to those patients who are really in pain but the doctor walks into the situation with the belief that he will be able to apply a well set rule which he either believes is foolproof and is confident that he can tell the fakers from those truly in pain from the substance abusers trying to get high. If a patient with severe chronic pain walks into an ER its because they have wrestled with making the decision to seek help knowing that he might be branded with the title “narcotics seeking behavior” which will do considerable harm to the patients state of mind all for the sole reason of worrying about letting a substance abuser fool the doctor into giving them narcotics for recreational use. The damage to the psyche can be so severe as to cause the person to commit suicide or at least make an attempt. Nothing on the face of this planet is worth risking that from happening merely so that the doctors ego doesn’t get bruised by allowing himself to be fooled. How do I know about this? It’s because I’m one of those people to whom this has happened. In my last attempt I took a razor and started slashing my throat open. It was a nightmarish image that will remain in my mind for the rest of my life because some ignorant doctor claimed that my pain is
“all in your mind.” You need to understand what damage you are causing a person who is asking you for help and you tell him to get lost and don’t seek narcotics at your ED. I’ve had Acute Myloid Leukemia before and fighting that was a cake walk compared to fighting chronic pain from degenerative disk disease. Almost all doctors seem incapable of understanding what chronic untreated pain can do to a person’s mind. Being dismissed as being “weak minded and not able to suck up the pain” is an absolutely horrible thing to put on a person who has suffered as much as I have. Before you go to bed tonight praise God that you don’t suffer from chronic pain folks.

I’m a new nurse, and have been reading up on determining the difference between pain seeking patients and patients truly in pain. It seems that the characteristic of patients requesting the drug to be pushed fast – faster than recommended practice – is the biggest red flag for me, along with patients who request a combination of IV drugs (e.g. Benadryl delivered with Dilaudid), but doesn’t seem to be covered in what I’ve read. More often than not, the patients who I think may be pain seeking tend to know that other nurses push a drug fast (despite this practice being against protocol), will get raging mad if you insist on pushing the drug slow and/or dilute it, and request a drug cocktail.

Dear Jane – I would like to recommend rethinking your position on this point. I don’t know if you’re aware of it but with some people opiates make them itch really bad. Benadryl stops the itching. Also, when a person goes to the ER it’s because their pain has become too much for them to handle on their own. You then need to take into account the fact that anybody who is in pain wants not to be in pain and the faster the better. Please don’t judge us too harshly because people like myself who live with chronic pain want our pain to go away as soon as humanly possible. Chronic pain is a hideous disease. It never gives you a moment’s peace. When we with chronic pain go to an ER then you can be certain that we’re at a level of desperation for the pain to stop that we are willing to endure the terrible irritation of waiting in an ER. Waiting in an ER when they are in pain makes people anxious. It’s a well-established fact that anxiety magnifies the perception of the pain that someone is experiencing.

By the way, I’m confused over the use of your terminology. Why do you refer to this as “pain seeking”? People aren’t seeking pain. They’re people who are in pain seeking a reprieve from the pain.

I’m a nurse, and I also have chronic pain, at 36. I received a dose of dilaudid before, for gall stone pain. It wiped every drop of pain in my body right away…felt so relieving. I felt the pain coming back a little while later, well, I was anticipating it in fear because it was so bad and I was now feeling so pain free. I told the nurse, and I was quickly discharged with a prescription for vicodin and referral to GI surgeon. I got the prescription filled , used it a day or so, along with some home remedy lemon water I found online, and I was good as new, back to my old chronic neck and back pain. I was used to my chronic pain, and only needed a little ibuprofen once in a whole if it got unbearable. I didn’t over due the ibuprofen because I also have ulcers and hemorrhoids…..yes, I’m in bad shape.
So,my take in this situation….pain med seeking……is that It sickens me. Do you know how it feels to be late medicating a 75 y/o hip fracture, or 18 y/o appe, chole, kidney stone, bone fracture….All c/o 3/10 pain?All the while I’m coddling some 36y/o with 10/10 mystery pain not backed up by any diagnostic pathology with IV diluadid plus cocktail every 2 hours. The emergency room and hospital are for people with life threatening, acute conditions. I’m am so thankful they didn’t give me anymore dilaudid. I swear I was scared passing gas would hurt, …..but I didn’t get it, and guess what, I didn’t die. I still have my gallbladder, stones and all. I know it will go bad soon, but I have a host of comorbidities, and everything is manageable. I can wait until an acute intervention is unavoidalbe. I’m not suffering, and I’m not crazy, I just do what health professionals have to constantly do…consider the risk of excessive treatments……prolonged hospitalization, infections, scar tissue and lesion pain, med interractions…..and ADDICTION….to meds AND ATTENTION! The amount of money WASTED in America’s health care system is astronomical. The government thinks hcapps have an impact on decreasing health care costs….
Yeah right! The government is forcing hospitals to turn nurses and doctors in to drug dealers, hooking both naive and manipulative patients left and right. But guess who gets the best, most accurate care, the 75 y/o hip replacements and youngsters with appes, choles, stones and fractures. Their pain meds are apprpiately reduced, and mobilization encouraged. Before long, they are good as gold. Prolonged use of IV pain meds and and po narcs have direct negative effect on recovery. Obviously…..chronic pain and pain med addiction are not being adequately addressed or treated in the acute care setting. Addicts and middle aged people who just want to numb their bodies and emotions for a while should seek treatment elsewhere, from doctors and nurses that specialize in coddling and baby sitting egos.
Im not trying to be insensitive or judgmental, I just see a disfuctional system that is draining our nation. Like EMS workers and police officers, nurses and doctors suffer ptsd from the mental anguish caused by drug seekers, especially like some of the ones on here threatening to complain and cause extra paperwork. WOW.

So, as to cause myself less anguish and dread….I’m giving up on discouraging pain med addicts…intentional, or not. You can have whatever they prescibe, as soon as I can get it to you, and I will ask for whatever you request…as long as it’s not unsafe at that moment. I no longer care about your risks for pneumonia and peristalsis. If you want a chopped up stomach and intubation…..be my guest…..then you can get even more pain meds….yay for u. So….just keep on coming, keep on asking for more, until you finally aquire something to instantly qualify you for the max dose iv pain, nausea, itching, anxiety, depression, psych cocktale. Hopefully, u won’t overdose, or have an MI or CVA from severe bradycardia aND hypotension…..maybe. But then, you can always just get more pain meds for that too. Maybe you won’t fall,…and not get up…..be found down with renal failure from rhabdo..that really sucks, but they have pain meds for that too. And the gi fistula and resection you need after peristalsis and sbo can also be treated with some good old high dose dilaudid.

So, have no fear….I’m here to respect your pain, and keep u comfy. I’ll tell granny next door to put a sock in it if she waits 8 whole hours for her 25 mg of po tramadol, right when your q 2 hour cocktail is due…..boy she’s got nerve.
Despite what how it seems, I’m not insensitive, just frustrated with an ineffective treatment plan. There are so many other ways to treat pain besides narcotics. GOOD OUTPATIENT specialists should embrace their specialty, even for the indigent, so that acute care facilities and adequately treat their own specialty population.

You are an extremely judge mental person who I pray never to have you come near me, let alone treatment! You are full of hateful attitudes and really should not work with fragile people! I have chronic pain since youth and I always knew nurses were making these nasty judgements but you clearly can’t see how entrenched your abusive thinking is; please leave nursing to the truly compassionate among us!

Jane, it is actually very common for normal pain management to include narcs with Benadryl or Phenergan to relieve the possible side effects of the narc. Now one thing I want to point out is someone who is physically addicted to narcs are going to be in pain, so they are not in essence lying about their pain. Who is at fault for this addiction/are we helping the problem by treating the physical addiction, that is up for debate.

I would also like to point out that many cases I think it is very similar to our super bugs now. Are we going to not treat patients that have a resistant bug because they more than likely took ABs inappropriately. What about someone who comes in with a bleeding ulcer because of their alcohol addiction. Cancer r/t tobacco addiction. Can we say we will not treat you because you are to blame?

I would never say go against guidelines on any medication or give drugs against MD orders but to say that the patient is drug seeking because they are always saying it is a 10 is not justified. What likely happens is these patients are on 1 of dilauded q4 for weeks or months. We send them home of Percocets q6. Of course they will hurt because they are detoxing from the drugs we gave them and we did not order a consult for pain management or someone who can work through this secondary issue.

This patient may find drugs on the street that relieve the detoxing pain. this eventually turns into herion because of the cost associated with the increasing tolerance that is developing. and when this person can not get what they need to not detox they come to the ED because they do have a pain of 10 r/t detoxing off of narcs.